To submit a prior authorization online, please click the button below to use the web form.
PDF forms are available below to submit a prior authorization through fax.
| Title | Categories | Update Date | Download |
|---|---|---|---|
|
Compounding Coverage Authorization Request Form 1 651 downloads |
BCBSAL | December 3, 2020 | Download |
|
FDA Medwatch Form 1 475 downloads |
BCBSAL, BCBSFL, HiLab, sscripts | December 15, 2020 | Download |
|
FDA MedWatch Form 3500 1 72 downloads |
BCBSAL | December 15, 2020 | Download |
|
General-PA Form 1 11595 downloads |
BCBSAL | November 11, 2021 | Download |
|
Opioid PA-Request Form 1 911 downloads |
BCBSAL | November 11, 2021 | Download |
|
Part D Form 1 378 downloads |
BCBSAL | December 4, 2020 | Download |
|
Pegasys 1 62 downloads |
BCBSAL | November 11, 2021 | Download |
|
Specialty Pharmacy Form 1 3491 downloads |
BCBSAL | December 4, 2020 | Download |
|
Suboxone Subutex Prior Authorization Request Form 1 259 downloads |
BCBSAL | November 11, 2021 | Download |
|
Substance Abuse Authorization Form 1 81 downloads |
BCBSAL | November 11, 2021 | Download |
|
Synagis Authorization Request Form 1 105 downloads |
BCBSAL | December 4, 2020 | Download |
|
TNF Biologic PA Form 1 988 downloads |
BCBSAL | November 11, 2021 | Download |